List date(s) this work was published or aired.
Aug-12
Provide a brief synopsis of the story or stories, including any significant findings.
Sometimes a hospital stay is not really a hospital stay — as least as far as Medicare billing is concerned. And that tiny-seeming bureaucratic difference can add up to thousands of dollars in surprise medical bills for seniors. In her revealing look at one of the odder wrinkles in the Medicare coverage relied upon by 45 million Americans, Money writer Amanda Gengler explains why hospitals are increasingly putting patients on “observation” status instead of admitting them as inpatients. Although observation patients wear the same paper gowns and plastic bracelets as regular patients do, they are not covered by Medicare’s low-deductible Part A hospital coverage. Instead, they end up covered by Medicare Part B, in which they typically are on the hook for 20% of all their costs. And the costs of being admitted under observation are even higher if you need extra care after your hospital stay, as Gengler shows by following retired teacher Laraine Sickels’ progress through the confusing billing system. Because Sickels, who spent four nights in a hospital after breaking her pelvis, did not have three days as an inpatient, the skilled nursing care she needed was not covered — resulting in a $7,000 bill. Gengler’s balanced, in-depth reporting on this topic reveals how the use of observation status has been driven by concerns for reducing fraud and controlling costs — worthy policy goals as Washington seeks to rein in entitlement spending. But whether patients get on observation status is increasingly determined not only by your doctor but through black-box algorithms produced by a handful of hospital-consulting companies; few Medicare enrollees know going in the important financial consequences of these decisions, or are in a position to successfully appeal them once they’re made. Gengler’s reporting both forewarns Medicare enrollees about the surprise costs that can come with a hospital stay, and deftly and clearly lays out a complex public policy issue that is likely to become ever more urgent as the cost of health care continues to grow.
Explain types of documents, data or Internet resources used. Were FOI or public records act requests required? How did this affect the work?
The lawsuit filed on behalf of Medicare beneficiaries — Center for Medicare Advocacy vs. Kathleen Sebelius, Secretary of Health and Human Services — along with the responses filed by the parties to the suit and a related brief filed by the American Hospital Association, provided crucial background for the story. After repeated requests, the American Medical Association shared a letter it had sent to the Centers for Medicare and Medicaid Services about the problems with observation status, as well as the response from CMS. Other publically available documents used for the story included materials from the Medicare Payment Advisory Commission and CMS documenting the rise in observation and government discussions of the issue. Gengler also dug up hospital audits buried on the Government Accountability Office website, which showed that hospitals are being dinged for admitting patients as inpatient that auditors later deemed belonged in observation. She also went through hundreds of pages of medical records provided by real people, in one case uncovering that the patient was initially admitted as inpatient before the decision was reversed to observation.
Explain types of human sources used.
To report this story, Gengler spoke to experts representing every party involved in the decision about whether to admit or observe a patient, including emergency room doctors, hospitalists, social workers, nurses, and the case managers who review the doctors’ decisions and apply the guidelines, as well as the outside consultants used by hospitals when a disagreement arises. Experts from the Center for Medicare Advocacy contributed to the reporting as well. Gengler also spoke to all of the relevant professional associations, including the American Hospital Association, the American Medical Association, and the American Case Management Association. And she interviewed a representative from the leading outside firm that develops the guidelines about whether to admit or observe patients. Finally, Gengler interviewed more than ten former patients who had been held in a hospital under observation, or a family member.
Results:
After the story was published, the magazine heard from many in and out of the medical profession. To date, the story has not produced any changes to public policy or hospital billing.
Follow-up (if any). Have you run a correction or clarification on the report or has anyone come forward to challenge its accuracy? If so, please explain.
The magazine did not run any corrections or clarifications.
Advice to other journalists planning a similar story or project.
Gengler writes: When it comes to hospitals and the health care system, there is a wealth of public information buried in government websites. Because Medicare is the largest payer in the health care system, you can often use Medicare data to spot trends taking place in the broader health care system. You can also find out a great deal about a hospital’s quality of care and bottom line. So take advantage of that public information.